((If trainees do not note the right shoulder tip pain or fail to recognise Kehr's sign: patient volunteers 'my right shoulder is killing me too — is that weird?' prompting reassessment of abdominal injury significance.))

((If oxygen is not applied within 3 minutes of assessment: SpO2 drops to 93% on room air, respiratory rate increases to 28, patient becomes more anxious and restless.))

((If trainees do not recognise haemodynamic instability — low BP 88/60, HR 118, CRT 3s, pale/diaphoretic — and fail to treat as time critical or call for Priority 1 transport within 5 minutes: patient's GCS drops to 12 (E3V3M6), BP falls to 78/50, HR rises to 134, patient becomes increasingly confused.))

((If trainees attempt to palpate the abdomen forcefully or repeatedly: patient cries out in pain, becomes distressed, and attempts to pull away — reinforce that gentle single palpation of four quadrants is sufficient and repeated examination increases patient distress.))

((If trainees fail to recognise guarding and rigidity as signs of peritoneal irritation and do not flag this as a time-critical finding: facilitator prompts — 'What does the rigidity of the abdomen tell you about what may be happening internally?'))

((If trainees attempt to remove or cover the abdominal bruising area without first exposing and fully assessing all four quadrants: facilitator prompts — 'Have you completed your full exposure and secondary survey of the abdomen?'))

((If trainees do not minimise on-scene time and attempt lengthy procedures before transport: facilitator states — 'It has now been 8 minutes on scene. What is your priority here?'))

This patient is suffering from significant blunt abdominal trauma with haemodynamic instability secondary to suspected internal haemorrhage, and developing peritonitis indicated by guarding, rigidity, and Kehr's sign (right shoulder tip pain from diaphragmatic irritation).

• Ensure scene safety and don appropriate PPE on approach.
• Perform Primary Survey with c-spine consideration — mechanism involves significant blunt force but patient is ambulant; apply clinical judgement regarding spinal precautions given abdominal injury presentation.
• Recognise haemodynamic instability: BP 88/60, HR 118, CRT 3s, pale/cool/diaphoretic skin — identify this patient as time critical.
• Immediately call for Priority 1 transport and pre-notify receiving facility with patient details, mechanism, and clinical findings — minimise on-scene time.
• Manage airway: confirm patent airway, patient maintaining own airway; reassess continuously.
• Administer oxygen via non-rebreather mask at 15 litres per minute — titrate to target SpO2 94–98%.
• Perform gentle palpation of all four quadrants of the abdomen — identify tenderness, guarding and rigidity; do NOT repeat palpation unnecessarily.
• Recognise right shoulder tip pain as Kehr's sign — indicative of diaphragmatic irritation from intra-abdominal pathology (e.g. splenic or hepatic injury with blood tracking to diaphragm).
• Do NOT apply direct pressure to the abdomen — this will worsen peritoneal irritation and patient distress.
• Position patient supine or in position of greatest comfort; avoid unnecessary movement.
• Perform vital sign survey: BP, HR, RR, SpO2, GCS, CRT, temperature — document all findings.
• Perform Secondary/CNS Survey — assess for any additional injuries (chest, pelvis, long bones) given significant mechanism.
• Do NOT administer oral fluids or anything by mouth — surgical intervention is likely.
• Monitor persistently: record full observations every 5 minutes given time-critical status — note any deterioration in GCS, BP, or HR.
• Reassess airway and breathing continuously — if patient deteriorates to GCS ≤8 or stops protecting airway, prepare to assist ventilations with BVM.
• Provide continuous reassurance to patient — explain all interventions, keep patient calm and warm.
• Handover to ambulance crew using IMISTAMBO: Identity, Mechanism, Injuries found, Signs and vitals, Treatment given, Allergies, Medications, Background history, Other relevant information.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Abdominal Trauma · Haemorrhage · Hypovolemic Shock · Oxygen Delivery · Primary Survey · Secondary & CNS Survey · Trauma Management Principles